Inspection on 06/09/05 for Seeleys House

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Seeleys House 06/01/09

Seeleys House 16/04/08

Seeleys House 12/04/07

Seeleys House 28/12/06

Seeleys House 30/05/06

Seeleys House 22/03/06

Seeleys House 31/03/05

Seeleys House 30/11/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Seeleys House Campbell Drive Knotty Green Beaconsfield Bucks, HP9 1TF Lead Inspector Sue Smith Announced 6 September 2005 at 10:00 am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Seeleys House Address Campbell Drive, Knotty Green, Beaconsifield, Bucks, HP9 1TF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01494 670902 Buckinghamshire County Council Mrs Wendy Rutland Care Home 12 Category(ies) of Learning Disability registration, with number of places Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/3/05 Brief Description of the Service: Seeley’s House is registered to provide respite care at any one time for up to 12 people with learning disabilities. There is a rolling programme for respite care. The home is sited in a residential area of Beaconsfield and is owned by Buckinghamshire County Council. It is an adapted old school and provides single accommodation for service users with shared social space. Half of the building provides Day Care Services and is also owned by the Council. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection of the Service, which took place over 7 hours. The Manager was available throughout the Inspection. For most of the day there was one Service User at home who spoke at length with the Inspector, other Service Users were involved in their daily programme away from the Home, returning for the last hour of inspection. One visitor was spoken with during this inspection. Two members of staff were available throughout the Inspection, spending time with the Inspector discussing the commendable fire procedures and recording systems they had implemented throughout the Home. The Inspector conducted a full environmental tour and assessed a variety of records, which included, Medication, Careplans, Health & Safety, Recruitment, Assessment tools and Fire procedures. Staff were observed interacting with Service Users and each other throughout the inspection. 32 standards were assessed during this inspection of which 29 were fully met and 3 were partially met. Requirements under standards 9, 39 and 42 were received to further improve the Service. The Inspector would like to thank the Service Users and staff for the warm welcome and support given to complete this inspection. What the service does well: Pre-admission assessments and supporting ongoing assessments are in place to ensure Service User needs can be met before admission to the Home. Careplans are in place to support Service Users to maintain their health, personal care, social and spiritual needs whilst in residence. Health Passports are used as a valuable tool for supporting Service Users both internally and external to the Home. Service Users are supported to access a variety of amenities and activities whilst in residence. Meals are nutritiously balanced taking into consideration the likes, dislikes and cultural needs of individuals. Care is implemented using a flexible person centred approach. Medication procedures are implemented according to policy and procedure to ensure the protection of Service Users. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 6 An accessible and comprehensive complaints procedure is in place with no formal complaints made to the Home or directly to the Commission in the past 12 months. The Home is cleaned to a high standard with infection control measures in place. Recruitment procedures are robust and ensure the protection as far as is reasonably practicable of Service Users. Staff exhibited a commitment to ensuring Service Users needs are met with a flexible approach to implementing care evident. Service Users were complimentary of the care and support offered. A regularly updated programme of training is in place to ensure the development of staff and the protection of Service Users. The Manager is competent and has a clear understanding of the national minimum standards and how best to meet these within Seeley’s House. Records are maintained in line with the Data Protection Act 1998 ensuring information remains confidential. Health and Safety systems in the Home further support Service Users to live in a safe environment. The Staff team are proactive in implementing change, which will enable Service Users to reside in a safe, relaxed and homely environment. What has improved since the last inspection? What they could do better: The Home received 3 requirements to support them to further improve the facilities and systems in place. The Responsible Individual is required to ensure Regulation 26 visits (monthly proprietor visits) are undertaken as part of the quality monitoring systems for the Home. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 7 The Home needs to ensure all Service Users who require bed rails undergo a full documented risk assessment before use. Acoustic hold open devises will need to be fitted to the 2 front offices in line with the recent Fire Authority requirements. The local Fire Authority has given permission for the fitting of these devises. A recommendation has been given as a result of this inspection for a review to take place of the maintenance and decorating budget in place. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3. Information is made available prior to admission, ensuring Service Users are choosing a Home that is able to meet their needs. A full pre-admission assessment is undertaken to ensure the Homes staff are prepared for admission and are able to fully meet the needs of an individual. EVIDENCE: As Seeley’s House is a council run respite home, the admissions procedure differs from the usual expectations within this standard. Before a first time admission can take place a full Care Manager assessment is made available to the Home to determine the needs of the individual. Visits to the Home are offered to the prospective Service User, which include teatime stops and an overnight stay. During this time further assessment takes place to ensure the Service Users needs can be met and they are happy with the placement. The day to day admissions to the Home are Service Users who generally book in advance for example they may come to the Home one weekend each month or a set day to receive respite care. In these instances prior pre-admission assessments are held by the Home with regular documented reviews undertaken by the Home and the Care Manager. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10. A full plan of care is in place that enables staff to appropriately support Service Users, in line with their assessed needs. Generally Risk assessments are in place that outline individual vulnerabilities and control measures that enable Service Users to continue living their lives as independently as possible. However not all Service Users have a bed rail risk assessment as required which ensures risk measures are put in place to protect Service Users from harm. EVIDENCE: A full Careplan is in place, which comprises of a working file as well as a full information file. Once staff are made aware of booking, information is transferred into the working file to ensure up-to-date and relevant information is accessible to staff during the Service Users stay at the Home. During the inspection one Service User gave her Health Passport to the Inspector to show the work that had been undertaken to support her. The Service User explained she had recently used this tool whilst on a hospital admission to aid the staff to understand her needs and previous medical Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 11 history. This initiative (throughout the county) has been a positive step to supporting Service Users in the wider community. Seeley’s House have placed emphasis on ensuring these documents are a working tool with changes and additions made to individual passports as needed. Feedback from the Service User and her family was very positive and they felt this document was an excellent aid to explaining individual needs and other relevant information. Risk assessments were on file, which support the Service Users to maintain their independence in a safe manner whilst at Seeley’s House. A requirement was given to the Home at the last inspection for risk assessments to be put in place for all Service Users requiring bed rails whilst staying at the Home. It was found on inspection this work has not been completed in some of the existing Careplans; therefore this requirement will be made again as part of these inspection findings with a 28-day timescale for action. Discussion with the Manager took place to ascertain why this had not been undertaken. The Inspector would remind staff to ensure all identified risk do have a full risk assessment in place which will protect the Service Users from potential harm whilst in residence at Seeley’s House. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 14, 15, 16, 17. Service Users are able to access a wide range of amenities which meet their social, leisure and spiritual needs. Seeley’s House promotes ‘flexible’ visiting to enable Service Users to maintain contact if wished during their stay at the Home. Care is implemented using a person centred approach, which enables Service Users to maintain their independence during their stay at the Home. Meals provided are nutritiously balanced and flexible to ensure the dietary needs of all Service Users is met on any given day. EVIDENCE: The Home does not operate a set activities programme as logistically this doesn’t work, however staff ensure that activities that meet the needs of Service Users residing in the Home on any given night are made available taking into consideration the likes and dislikes of the individuals. All outings are subject to a risk assessment before leaving the Home to ensure the safety Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 13 of Service Users. Family members are contacted if a lengthy trip is planned to ensure they are aware of the absence from the Home. Care and support is offered in a manner that ensures Service Users are able to maintain their usual independence. Each Service User has an individual plan of care, which outlines preferences. All care is implemented ensuring the privacy and dignity of the individual is maintained. The Service User spoken with on the day of inspection was complimentary of the care and support offered by staff and believed her own routines and preferences were maintained with staff exhibiting a flexible approach to meeting care needs. As some family members wish to maintain their daily contact with their relative during their stay at Seeley’s House the Home have implemented a flexible approach to receiving visitors, there are no restrictions on the times for visiting with staff welcoming visitors to the Home. The Home have been unable to secure the employment of a full time cook, due to this contingency plans are in operating with members of the team designated to prepare meals, all staff have undertaken the necessary food hygiene training to enable them to work competently in the kitchen. Meals offered take into consideration both the likes and dislikes of Service Users in residence as well as the cultural needs of some individuals. The Home continues to search for a designated cook realising this is not the most preferable of solutions, however on inspection the system is well managed and is designed to ensure the needs of Service Users continues to be met. Discussion took place with the Manager to share ideas to further improve this system. These are not reflected in this report as the Manager is proactive and the Inspector is satisfied the Home are more than capable of problem solving some of the issues raised by the Manager. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20. Service Users needs are outlined within their individual plans, ensuring the manner in which they are supported and cared for is appropriate and promotes their preferences. Healthcare support is planned and implemented in a manner that promotes the well-being and protection of Service Users. Medication procedures within the Home are robust with staff training in place, which ensures that Service Users’ are protected from any identified risks. EVIDENCE: As previously mentioned in this report care needs are implemented in a manner that best supports the individual using a person centred approach which has the flexibility to change planned care to support the Service User to maintain their own routines. There were no issues of concern raised by Service Users or family members during this inspection with both complimentary of the care provided. Medication procedures in the Home are of a high standard; mechanisms are in place to ensure all handwritten MAR (medication administration records) sheets are accurate. The Home has previous to this inspection sought the Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 15 support of the C.S.C.I. pharmacy inspector to address issues of concern and further improve the systems in place. The Inspector is satisfied all measures in place support the Service User and staff to administer medication in a safe manner. There appears to be some confusion with the local pharmacy in relation to the safe disposal of spoilt medicines, recent changes have necessitated all Nursing Homes to arrange their own disposal service. As Seeley’s House is a respite residential service these changes should not affect the current systems in place, further consultation will be necessary between the Home and the pharmacy to ascertain why the pharmacy believe Seeley’s House are not a designated residential service. The Inspector will leave this issue of concern to the Manager to problem solve; however should further issues arise the Manager is able to contact the Commission to aid a mutually agreed solution. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23. Service Users are supported to make their views and opinions known, therefore making them feel valued. Vulnerable adults are protected by thorough policies and procedures and wellinformed staff, which mean their intrinsic human rights, are protected. EVIDENCE: The Homes complaints procedure is readily available to Service Users and significant others to ensure all complaints are addressed within a recognised timescale. Service Users and families spoken with feel they are able to raise issues of concern with the Manager and the staff team and necessary changes are implemented to resolve the highlighted issue. At this time there have been no formal complaints received at the Home or directly at the Commission in the past 12 months. Service Users spoken with believed the manner in which care is implemented and the additional support they receive in day-to-day matters ensures they are able to voice their opinions and views. Staff were observed throughout the inspection communicating with Service Users, the Inspector was impressed with the way in which staff communicate on a one-to-one basis, with Service Users residing in a relaxed and homely environment. One Service User stated she would recommend Seeley’s House. The Manager and staff team are to be commended for their commitment to ensure all staff attended the Buckinghamshire inter-agency policy training for the Protection of Vulnerable Adults. All staff undertook this training and has a Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 17 clear understanding of the reporting systems in place and what classifications of abuse exist. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25. 26, 27, 28, 29, 30. Recent changes to the environment and equipment has taken place, which ensures the environment is designed to meet Service Users care, and comfort needs. Standards of cleanliness at the Home are of a high standard meaning Service Users live in an environment that is clean, hygienic and protects their health, safety and welfare. EVIDENCE: The Home has recently completed the fitting of new bathrooms with supporting equipment, which will meet the physical needs of Service Users. A new bathing table has been purchased to replace the equipment highlighted in the last report. In addition a new hoist has been purchased to further meet the needs of Service Users. A more realistic programme of decoration does need to be addressed by the council to ensure Seeley’s House is regularly maintained, as the wear and tear on the building is exasperated due to the damage caused by equipment such Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 19 as hoists and wheelchairs. Some bedrooms require cracks around doorframes to be plastered and painted with other bedrooms requiring a fresh coat of paint to rid them of scrapes on walls. The Inspector appreciates the Manager is not responsible for the overall maintenance budget and does ensure any areas of concern are reported immediately. As these areas highlighted are not a risk to Service Users at this time a requirement has not been made, however as previously stated the budgets do need to be addressed to ensure the Home is able to decorate individual areas of the Home as needed. All bedrooms are single accommodation and are large in size, Service Users are able to personalise these during their stay. There are sufficient toilets and bathroom in close proximity to bedrooms with adaptations and equipment in place to support the specific needs of Service Users. There is a large communal lounge and dining area, which leads to the patio area. Additional equipment such as a computer is stored in the dining room in pleasant cupboard units, which are in keeping with the rooms’ décor. The Home was found to be clean and free from offensive odour on the day of inspection with all items of C.O.S.H.H. locked away. The Home has systems in place to ensure the control of infection. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35. Recruitment procedures at the Home are robust, ensuring all necessary security clearances are in place before an offer of employment, this ensures as far as is reasonably practicable the protection of Service Users from abuse. Service Users benefit from well-informed staff, ensuring their care and support needs are appropriately and effectively met. EVIDENCE: The recruitment files of staff employed since the last inspection were assessed. All files were reflective of two written references, an enhanced CRB disclosure with POVA check, forms of identification and application forms, interview notes, job specifications and training records. All signed contracts are held at the main HR offices. Regular training is in place with a programme of planned training evident. The staff team are accessing external courses through Aylesbury College as well as the mandatory courses offered by the Organisation. All staff are up-to-date with mandatory training. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 21 Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 41, 42. The Manager is competent, possessing all the necessary skills and training to support her in the role, thus ensuring the protection of Service Users whilst in the care of the Home. Record are maintained in line with the Data Protection act guidance, ensuring Service User information remains confidential and their best interests are protected. There are systems within the Home that are used to ensure that Service Users health, safety and welfare are protected and promoted. EVIDENCE: The Manager has been in post for a number of years and has a clear understanding of the specific needs of Service Users as well as the administration and Management requirements of the Home. The Manager has a clear understanding of the National Minimum Standards and supporting Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 23 regulations and has worked hard to ensure the Home is working within current legislation. Staff find the Manager approachable with an open door policy. Staff supervisions are in place to ensure staff are able to discuss practice issues. Service Users and visitors spoken with were complimentary of the Management approach to the Home and feel empowered by this approach to raise any issues of concern and liaise with the Home as necessary. Monthly proprietor visits have not been taking place since the responsible individual has changed roles. The Organisation is reminded this is a necessary part of quality monitoring and is a requirement under Regulation 26 of the Care Standards Act 2000. Health and Safety systems in place further protect the Service Users whilst in residence. The Home ensures its fire procedures are of a high standard and the work staff have put in place to meet fire regulations are commendable. A recent Fire Authority report identified two office doors at the front of the Home as needing acoustic hold open devices as they were found to be wedged open during office hours. The Fire authority have given permission for the fitting of these devises, a requirement is made for the Organisation to ensure these are fitted within 28 days due to the length of time it is taking for this action to be implemented. Records of alarm testing and other equipment necessary for the prevention of fire were open to inspection, as previously mentioned staff are to be commended for the quality of these documents. In addition contract records were open to inspection for the maintenance of fire systems, these were found to be up-to-date. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Seeleys House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 2 x 3 2 x 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 (4) Requirement Outstanding individual risk assessments for bed rails must be put in place within 28 days of the inspection. Monthly proprietor visits must take place in accordance with Regulation 26 by the responsible individual or a designated person. Acustic hold open devices must be fitted to the two front offices as described in the April 2005 Fire authority report and additional correspondence from the Fire authority giving permision for the fitting of such devices. This work must take place within 28 days of this inspection. Timescale for action 6/10/05 2. 39 26 20/10/05 3. 42 13 (4) 6/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 24 Good Practice Recommendations The decorating and mainteance budget of the Home is reviewed during the new financial year to ensure funding is 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 26 Seeleys House available for the areas continuously damaged by equipment. Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 27 Commission for Social Care Inspection Cambridge House 8 Bell Business Park Smeaton Close Aylesbury, Bucks, HP19 8JR 01296 737550 National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Seeleys House 20050609 Seeleys House X00023 AI Stage 5 S32334 V237094 H53.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!